IJSPT

INVITED CLINICAL COMMENTARY

THE ROLE OF THE SCAPULA

Russ Paine, PT1
Michael L. Voight, PT, DHSc, OCS, SCS, ATC, FAPTA2

ABSTRACT
Previously, the scapular musculature was often neglected in designing a rehabilitation protocol for the
shoulder. In the past two decades a significant amount of research has been performed in order to help
identify the role of the scapula in upper extremity function. Weakness of the scapular stabilizers and resultant altered biomechanics could result in: 1) abnormal stresses to the anterior capsular structures of the
shoulder, 2) increased possibility of rotator cuff compression, and 3) decreased shoulder complex neuromuscular performance. This clinical commentary presents facts about the anatomy and biomechanics of
the scapula and surrounding musculature, and describes the pathomechanics of scapular dysfunction. The
focus is upon the assessment of dysfunction and retraining of the scapular musculature.
Keywords: scapular musculature, scapular biomechanics, shoulder rehabilitation, scapular strengthening
Level of Evidence: 5

CORRESPONDING AUTHOR

IRONMAN Sportsmedicine Institute at Memorial Hermann,

Houston, TX, USA
2
Belmont University, Nashville, TN, USA

Michael L. Voight
Belmont University, School of Physical
Therapy
1500 Belmont Blvd
Nashville, TN 37212
Email: Mike.voight@belmont.edu

The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 617

INTRODUCTION
The understanding of and interest in the role of the
scapula in upper extremity function has grown considerably in the past two decades. As understanding of the shoulder and surrounding structures
has increased it has become well accepted that the
scapula plays several roles in facilitating optimal
shoulder complex function when scapulohumeral
anatomy and biomechanics interact to produce efficient movement.1 In normal upper quarter function,
the scapula provides a stable base from which glenohumeral mobility occurs.1,2 Stability of the scapulothoracic joint depends on coordinated activity of
the surrounding musculature. The scapular muscles
must dynamically position the glenoid so that efficient glenohumeral movement can occur. When
weakness or dysfunction of the scapular musculature is present, normal scapular positioning and
mechanics may become altered.1,2 When the scapula
fails to perform its stabilization role, shoulder complex function is inefficient, which can result not
only in decreased neuromuscular performance but
also may predispose the individual to injury of the
glenohumeral joint.1,2
FUNCTIONAL ANATOMY AND
BIOMECHANICS
It is important that the clinician have a thorough
understanding of the muscles that control the scapula and normal scapular mechanics. Only through
an understanding of normal biomechanics can the
pathomechanics of injury or dysfunction be understood.2 The scapulothoracic articulation is one of the
least congruent joints in the body. No actual bony
articulation exists between the scapula and thorax,
which allows tremendous mobility in many directions
including protraction, retraction, elevation, depression, anterior/posterior tilt, and internal/external
and upward/downward rotation. When describing
scapular positions, the point of reference is the glenoid. The lack of an actual bony articulation in the
scapulothoracic region predisposes it to pathologic
movement, rendering the glenohumeral joint highly
dependent on its for stability and normal motion.1,3-6
The scapula is only attached to the thorax by ligamentous attachments at the acromioclavicular joint
and through a suction mechanism provided by the
muscular attachments of the serratus anterior and

subscapualaris.3 This suction mechanism holds the

scapula in close proximity to the thorax and allows it
to glide during movements of the joint.3
While many muscles serve to stabilize the scapula,
the main stabilizers are the serratus anterior, rhomboid major and minor, levator scapulae, and trapezii.
The glenohumeral protectors include the muscles
of the rotator cuff: the supraspinatus, infraspinatus, teres minor, and subscapularis.5-9 These muscle
groups function through synergistic co-contraction
to anchor the scapula and guide movement.3 Specifically, the muscles of the scapula function as
follows:
Serratus Anterior
The serratus anterior is an important scapular stabilizing muscle. It originates from the first eight ribs
and courses along the rib cage to insert along the
anterior medial aspect of the scapula. The upper portion of the serratus anterior insertion is spread along
the medial border of the scapula, while the lower
portion inserts into the inferior angle of the scapula.
Innervation of the serratus anterior is provided by
the long thoracic nerve, which arises from the ventral rami of the fifth and seventh cranial nerves. Due
to the multiple attachment sites, the primary role of
the serratus anterior is to stabilize the scapula during
elevation and to pull the scapula forward and around
on the thoracic cage. Advancement of the scapula to
an anterior position on the thoracic cage is termed
protraction or scapular abduction. The term protraction is more frequently used in describing this
anterior movement in order to avoid confusion with
shoulder abduction. The movement of protraction is
involved with pushing or punching type activities.
Three-dimensional studies have shown that the serratus anterior contributes to all components of 3-D
scapular movements during arm elevation, which
includes upward rotation, posterior tilt, and external
rotation.10,11
Rhomboids
The rhomboids (major and minor) function to stabilize the medial border of the scapula. The rhomboids
are very active in scapular adduction or retraction,
which can be defined as backward rotation of the
scapula toward the vertebral column. The rhomboid minor originates from the spinous process of

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the seventh cervical and first thoracic vertebrae and

inserts into the medial border of the scapula near
the base of the scapular spine. The rhomboid major
originates from the second through fifth thoracic
vertebrae and inserts into the medial scapular border of the scapula just below the insertion of the
minor. Innervation to both the rhomboid major and
minor is provided by the dorsal scapular nerve. If
rhomboid weakness is present, the scapula will be
unable to achieve full retraction. Full retraction is
essential not only for overhead throwing motion
but also for swimming strokes such as the crawl.
The inability to achieve the fully retracted position
during the throwing or overhead motion can lead
to increased stress on the anterior structures of the
shoulder.12 Activities that involve a pulling motion
may be affected by lack of rhomboid strength. Electromyographic (EMG) analysis has demonstrated a
high level of rhomboid activity during the acceleration phase of pitching.13 This EMG data suggests that
the rhomboids are contracting eccentrically during
the follow-through phase of throwing as the muscle
continues to contract eccentrically to brake the
energy released during acceleration.12 Therefore,
rhomboid strength is vital in throwing and overhead
arm movement. Strengthening this muscle group
should be emphasized when rehabilitating patients
with anterior instability.2

vertebrae 1-4. The insertion of the levator scapulae

is along the medial border of the scapula at the level
of the scapular spine. Innervation is provided by the
cervical plexus (C3, C4) with frequent contribution
from the dorsal scapular nerve. The levator scapulae
functions to elevate the scapula and tilt the glenoid
cavity inferiorly by rotating the scapula downward.
Exercises used to strengthen rotator cuff and scapulothoracic musculature are also effective in eliciting activity of the levator scapulae, making specific
exercises to target this muscle often unnecessary.14

Trapezius (Upper/Middle/Lower)
The trapezius functions include upward rotation and
elevation for the upper trapezius, retraction for the
middle trapezius, and upward rotation and depression for the lower trapezius. In addition, the inferomedial-directed fibers of the lower trapezius may
also contribute to posterior tilt and external rotation
of the scapula during arm elevation.10 The trapezius
takes originates from the medial third of the superior nuchal line, external occipital protuberance,
nuchal ligament, and spinous processes of C7 to
T12 vertebrae and attach distally at the lateral third
of the clavicle, acromion and spine of the scapula.
Innervation to the trapezius is provided by the spinal accessory nerve.

Normal Biomechanics
Mechanically, the coordinated coupled motion
between the scapula and humerus, often termed
scapulohumeral rhythm, is needed for efficient
arm movement and allows for glenohumeral alignment in order to maximize joint stability.15 Studies
examining the mechanics and role of the scapula in
shoulder function have progressed over time, with
the earliest studies examining two dimensional
scapular motion with the use of radiographs, dating
back to Inman et al in 1944.16 Inman et al16 found
an overall 2:1 relationship between glenohumeral
elevation and scapular upward rotation, which has
remained the classic description of the so-called
scapulohumeral rhythm.11 A more clinically relevant
analysis of scapular motion has been conducted in
several three-dimensional studies using surface markers and indwelling bone pins.10,11,15,17-19 McClure et al.11
found that during scapular plane elevation of the arm
in normal subjects, there was a consistent pattern of
scapular upward rotation, posterior tilting, and external rotation along with clavicular elevation and retraction.11 Scapular upward rotation is the predominant
scapulothoracic motion. The motion of the scapula
with regard to changes in scapular internal rotation
angles shows more variability across subjects, investigations, planes of elevation, and point in the range of
motion of elevation.11,20,21 It has generally been found
that end range elevation involves some scapulothoracic external rotation, however, some studies report
internal rotation during elevation and limited data
are available.11

Levator Scapulae
The levator scapulae originates from the posterior
tubercles of the transverse processes of cervical

PATHOMECHANICS
The role of the scapula in shoulder injuries has been
widely investigated with the majority of studies in

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the area of shoulder impingement and rotator cuff

disease, and fewer studies researching the role of
the scapula in shoulder instability and adhesive capsulitis or glenohumeral joint stiffness.15,21 Among the
research there is significant variability in subjects,
study design, kinematic description and outcomes.
However, most of the abnormal biomechanics and
overuse injuries that occur about the shoulder girdle
can be traced to alterations in the function of the
scapular stabilizing muscles.22,23 Altered scapular
motion and position have been termed scapular dyskinesis. The definition of dyskinesis is the alteration
of normal scapular kinematics.15 Many factors may
contribute to the development of scapular dyskinesis
including but not limited to bony causes, including
posture or previous fracture. Joint causes including
acromioclavicular joint instability, acromioclavicular joint arthrosis, and glenohumeral joint internal
derangement. Neurological causes including cervical radiculopathy or nerve palsy. Soft tissue factors
including inflexibity (tightness) or intrinsic muscle
problems, and alterations in periscapular muscle
activation.15
Of the possible contributors to scapular dysfunction
or dyskinesis, most commonly, muscles are either
injured via macrotrauma, have microtrauma-induced
strain, or are inhibited by painful conditions of the
shoulder such as labral lesions, arthrosis, or instability.8 Weakness of the scapulothoracic muscles potentially leads to abnormal positioning of the scapula,
disturbances in scapulohumeral rhythm, and generalized shoulder complex dysfunction.5 The serratus
anterior and lower trapezius are the most commonly
weak or inhibited muscles of the scapulothoracic
joint that may lead to abnormal movement.24,25 The
serratus anterior and lower trapezius contribute to
the important upward rotation force couple that produces acromial elevation. If part of that force couple
is altered, for any reason, movement is abnormal.
For example, paralysis of the serratus anterior
results in reductions in both glenohumeral flexion
and abduction. The medial border of the scapula
is elevated off the rib cage, resulting in decreased
acromial elevation. This problem manifests itself
through decreased shoulder abduction and secondary impingement.5 This lack of acromial elevation
and secondary impingement has been seen concomitant with many glenohumeral problems. Most

shoulder complex injuries incurred as a result of

sport activities can be traced to abnormal biomechanics, which, in turn, can be related to improper
functioning of the scapular muscles.8 In fact, scapular instability is found in as many as 68% of rotator
cuff problems and 100% of glenohumeral instability
problems.8,26
The effects of muscle fatigue with regard to scapular
stability have also been investigated. Thomson and
Mitchell27 investigated the effect of repetitive exercise on the scapular stabilizers by studying the ability
of the scapular musculature to stabilize the scapula
after fatiguing exercise in the proprioceptive neuromuscular facilitation (PNF) D2 pattern as measured
by the lateral scapular slide (LSS) test. Their results
suggest that a fatigue-induced strength deficit of the
shoulder musculature can have an adverse effect
on scapular positioning by allowing the scapula to
glide more laterally during functional activities.27
The effect of fatiguing exercise on shoulder muscles
has also been studied by Carpenter et al28 and Voight
et al29, who investigated the effects of exercise and
muscle fatigue on shoulder proprioception. Both
groups found a significant decrease in joint kinesthesia, measured using the time threshold to detection of passive movement after fatiguing exercise.28
They hypothesized that a decrease in position sense
as a result of fatigue of the shoulder girdle musculature could interfere with normal coordination and
joint stability, thus impairing function around the
shoulder girdle.28,29
Physical Exam and Assessment
It is well accepted that strengthening and motor control training of the scapular musculature is a vital
component to most shoulder complex rehabilitation programs. The difficulty with validating such
programs lies in the ability to measure changes in
scapular position. It has been difficult to assess and
track scapular motion secondary to the relatively
deep position of the scapula and overlying muscles.
This section on physical exam and assessment will
present clinical examination tools for clinicians
use in evaluating scapular asymmetry of weakness.
Most methods for evaluating scapular dyskinesis
involve some sort of tool, test, or observation in a
single plane. This presents a problem due to the
three-dimensional nature of scapular movement. In

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Figure 1. (a) Wall push press into wall using ngertips.

Avoid leaning into wall with body. Observe backward winging
of the scapula. (b) Lift 3-5# dumbbell and lower to position
shown (45 degrees). Observe backward winging of scapula.

addition, another difficult challenge with scapular

evaluation is attempting to extrapolate how much
weight to give a special test that shows a unilateral
deficit. In many cases, such as overhead baseball
throwers, unilateral asymmetry can be found in normal, asymptomatic subjects.30 Scapular dyskinesis is
generally characterized by a lack of upward rotation,
a lack of posterior tilting and increased internal or
medial rotation of the scapula.21 Kibler has described
a re-location test of manually re-positioning the scapula to reduce or eliminate a painful arc. This test was
described by Kibler as the scapular dyskinesia test
(SDT) test.15 Interrater reliability for Kiblers test is
moderate to fair at .42 and .32 for physical therapists
and physicians. This test is a visual interpretation of
scapular dyskinesia involving several subcategories.
When this test was simplified as a yes or no for
dyskinesis, the reliability scores were improved. A
similar reliability study was performed by McClure
and Tate. They found interrater reliability among
visual observers of .57 for the active SDT.31 indicating moderate reliability. Criterion was based on
normal, subtle, or obvious scapular dyskinesia. It
appears that loading the shoulder by performing
a forward flexion lift with a dumbbell seems to be
the best position to reveal any lack of scapular con-

trol. Another method to reveal scapular stability is

a wall push (Figure 1a). This test was described in
the authors original article.2 This test is performed
in a similar method to the dumbbell lift performed
in forward flexion (Figure 1b). Figure 2 illustrates
scapular asymmetry, with prominence of the right
medial scapular border. Clearly, rehabilitation professionals are still searching for a reliable method
of scapular physical examination techniques. As a
comparison, the KT-1000 knee ligament arthrometer
demonstrates very high intertester reliability. This
instrument is used for diagnosing an ACL tear, by
measuring millimeters of anterior tibial translation
of the tibia on the femur. Myer found interclass correlation coefficients (ICC) between examiners to be
.92 for absolute millimeters of displacement.32 The
authors applaud all authors efforts to provide the
sports medicine community with answers to objectifying measurements of scapular position.
Evaluation of other soft tissue structures around the
shoulder should be included during scapular examination. Posterior shoulder tightness is thought to be a
contributing cause of the anterior tilted scapula. Borich
et al showed a correlation between decreased internal
rotation and anterior tilted scapula in normal subjects.33
Laudner showed a moderate correlation to posterior

Figure 2. Notice prominence of the medial border of the right

scapula during only a ngertip press into wall.

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shoulder tightness and forward scapular posture in

baseball players.34 Launder believes that increased laxity in baseball pitchers may contribute to a downwardly
rotated scapula. In his study, pitchers were shown to
have a more downwardly rotated scapula when compared to position players. Laudner theorized that
increased laxity in pitchers creates a lack of capsular
tension that allows the scapula to drift inferiorly.35
Figure 3 demonstrates the genie stretch described
by Paine.36 This stretch focuses on the posterior soft
tissue restriction of the shoulder. When performing
this stretch, external rotation is controlled, placing
the tight posterior rotator cuff and capsule on tension. This technique is believed to impart a more
focused stretching rather than pulling into horizontal
adduction with no control of external rotation. Wilk
(personal communication) has described a sidelying version of this stretch to help reduce scapular
movement. The patient is sidelying on the affected
side and rolls onto the scapula while performing the
movement of the genie stretch.

Therapeutic Exercise Design

The rehabilitation program for scapular dyskinesis
should address all of the contributory impairments
found during the evaluation process. By doing so,
the clinician should be able to restore the balance
of musculature that allow for normal static scapular
position and dynamic motion. Before beginning a
corrective strengthening program, the clinician must
regain normal flexibility of the muscles about the
scapula if identified, as tightness or adaptive shortening can inhibit activation of opposing muscle groups.
It is common to find tightness of the pectoralis minor
and posterior glenohumeral capsule in patients with
scapular dyskinesis. Borstad and Ludewig found
increased internal rotation and anterior tilting of the
scapula in subjects with a short pectoralis minor.20
Therefore manual therapy and stretching of tight
structures can be employed early in the rehabilitative
process. Once normal flexibility has been achieved, a
conscious motor control-strengthening program can
be initiated to help normalize the scapular resting
posture. As the patient is progressed through the program, emphasis will shift to dynamic control in order
to restore muscle balance with various arm movements. Once muscle balance is achieved, the final
emphasis is on scapular muscle strengthening within
sports specific movement patterns. The following is
an outline describing a typical phased implementation of various scapular strengthening exercises. This
exercise routine was designed based upon muscular
activation identified in prior EMG studies.37-42
Phase I
The beginning phase of scapular strengthening is
designed to initiate firing of the muscles that control the scapula. Depending on the type of scapular
dyskinesia or weakness present, select the appropriate exercise to address the physical exam findings.
Please see figures for all exercise descriptions.

Figure 3. Genie Stretch Begin stretch in Genie Position

with involved arm below normal. Limit external rotation using
top arm as the control arm. Lift the elbow slightly then pull
across chest in a diagonal movement. Make sure that subject
perceives stretch on top and or posterior aspect of shoulder.
Coracoid impingement will occur if subject feels pinching in
front. This can be avoided by lowering angle towards opposite
hip.

Isometrics
Isometric squeezing exercise may begin with many
post-operative patients or those that are having significant pain with active elevation exercises.
1. Scapular pinches: Squeeze shoulder blades together
and hold for 3 seconds
2. Robbery pinches: Squeeze shoulder blades together
and hold for 3 seconds in a position described by

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Kibler37 (see Figure 6: Swiss Ball Robbery exercise

for position).
3. Low Row Wall isometrics: With back against wall,
arms to side and extended, push fingertips into
wall, holding 3 seconds.
Isotonics
Advancement to active glenohumeral/scapular
joint movement occurs when painful arc symptoms
are diminished. These exercises use light resistance
with emphasis on proper technique. The authors
suggest 3 sets of 10 to 20 repetitions, with 3 second
holds.
1. Scapular pinches using theraband: Using tensioned theraband in front of body, spread theraband by pinching shoulder blades together. It is
very important to keep elbows tucked to side during entire routine.
2. Low Row Theraband: Standing with arms to side,
loop theraband around stable object, and pull both
arms into extension behind body squeezing lower
scapular muscles.
3. Dynamic Hug: (Figure 4) Place single theraband
around back grasping band with both hands in
front, perform hugging motion to perform protraction of scapula

Figure 4. Dynamic Hug - using cable column, can also be

performed using Theraband. Instruct the patient to reach forward as if hugging a tree. Target muscle, serratus anterior.

4. Scapular Punches: Affix theraband to door approximately shoulder height. With back to door grab
theraband and mimic punching motion making
sure to achieve full protraction.
5. Cheerleader Exercise: (Figure 5) Using single piece
of theraband held with both hands in front of body,
elbows completely extended, pull theraband apart
in bilateral horizontal abduction. Return to starting position, then pull theraband in D2 diagonal

Figure 5. Cheerleader Exercise Using Theraband, perform alternating diagonal patterns with one bilateral horizontal abduction
motion between each diagonal. Target muscles, lower trapezius, rhomboids.
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position with right arm up, then alternate into D2

diagonal with left arm up.
Phase II
This phase of scapular strengthening is usually instituted when there is minimal/no pain in the shoulder
complex with lifting arm overhead, although some
exercises could be used at an earlier time frame if
non-painful.
1. Seated Rows: Seated on a bench, using a cable
column or row machine, pull handles into sternum while pinching scapulae together, toward the
spine. Pinch and hold scapulae then extend arms
and allow scapulae to assume a fully protracted
position and repeat. It is very important to keep
elbows tucked during entire exercise. Note, this
exercise can also be performed unilaterally.
2. High Rows: same exercise as above, raising cable
column to higher position and pulling handles
downward into chest.
3. Swiss Ball Robbery: (Figure 6) While lying on
stomach on Swiss ball, place dumbbells in front of
body on floor. Grasp dumbbells and retract scapula to achieve the robbery position while maintaining spine extension. This allows posterior
chain strengthening along with lower trapezius
strengthening.

Figure 6. Swiss Ball Robbery Prone on a Swiss Ball,

assume robbery position, cuing patient to point elbows to
back pockets. Target muscle, lower trapezius.

4. Standing D2 Cocking Cable Column: (Figure 7)

While in standing position, using either theraband
or cable column, starting hand in position across
the body and around shin height, pull upward at
a diagonal to achieve Statue of Liberty position.
Return, with control, to start position and repeat.
5. Latissimus Pull Downs: Keeping bar in front of
the body, pull down handle to chest level, flexing
elbows, in order to exercise lower scapular musculature (downward rotators).
6. Manually Resisted Scapular Strengthening: (Figure
8) Manual resistance from therapist in sidelying
position to attempt to isolate scapular movements. Can emphasize pro/retraction, elevation/
depression, upward/downward rotation, and PNF
diagonals.
Phase III
This phase is comprised of advanced scapular exercises and may not be necessary for all individuals. It
incorporates closed chain activities and more aggressive, sport specific techniques.

Figure 7. Cocking Cable Column Perform D2 diagonal pattern pulling into a cocked position, then slowly lower to decelerate. Target muscles, lower trap, rhomboid, posterior cuff.

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Figure 8. (a) Manual Resisted protraction/retraction Manual resistance applied to anterior shoulder and spine of scapula while
patient performs protraction, retraction. Target muscles, serratus anterior and rhomboids. (b) Bilateral PNF Manual resisted D2
bilateral PNF pattern. Target muscles, lower trap, rhomboid, posterior cuff.

1. Super 6: (Figure 9) A series of scapular exercises

that involve reciprocal movements of both arms.
2. Standing Cable Column Punch: Using long bar
attached to cable column, perform a punching
(with protraction) type maneuver with cable column resistance.
3. Bear Crawl on Swiss Ball: (Figure 10) With legs on
Swiss Ball and trunk extended, maintaining neutral spine, walk out on hands and perform pushup, then crawl back to start position using hands.
4. Plyoball Deceleration: With subject kneeling, throw
a small (2#) plyoball from behind asking patient to
catch and decelerate into internal rotation.
5. Seated Pike lift: (Figure 8) Using 2 boxes or large
dumbbells, have patient place hands on boxes or
grasp dumbells and lift buttocks off table or floor.
Goal: 20 second holds.
6. Standing Snow Angels: (Figure 12) With back
against wall perform overhead pressing maneuver and touch hands together above head. Patient
attempts to keep back of hands, forearms, and
scapulae against wall. Light cuff weights are used
for resistance.

Supportive Devices
The need for increased awareness of scapular position and stability during movement, as well as correlation to positive clinical outcomes has led to the
development of accessory tools to enhance scapular positioning with activity. Several manufacturers
have developed scapular shirts, an external, tight
fitting device, sewn in a manner that promotes an
upright posture of scapular retraction and upward
rotation. Scapular taping is used by some clinicians
for proprioceptive feedback to the scapular musculature. The authors preferred method is use of the
scapular shirt. (Figure 13)
CONCLUSION
The shoulder complex must be considered a part of
a larger kinetic chain made up of several joints. It
is obvious that the glenohumeral joint and scapula
cannot function independently. Clearly, dysfunction at either joint has a direct effect on the other.
The function of the scapula and surrounding musculature is vital to the normal function of the glenohumeral joint. As knowledge regarding the role
of the scapula continues to grow, improved evaluation and treatment approaches for dyskinesis continue to evolve. While rotator cuff strengthening has

The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 625

Figure 9. (Super 6 Scapular Routine (a-f) Series of reciprocal scapular exercises that target scapular, rotator cuff, and trunk musculature. a.Upright Row, b. Dynamic Hug, c. Cocking/Deceleration, d. Cocking/Acceleration, e. Bilateral D2, f. Bilateral Pullover

Figure 10. Bear Crawl Walk out on hands while in a plank

position on swiss ball, then perform push-up with a plus. Target muscles, serratus anterior, pectoralis major.

been an obvious treatment for various pathologies,

the origins of the rotator cuff muscle arise from the
scapula, therefore an effective exercise program for
rehabilitation should include improving the strength
and function of the muscles that control the position

Figure 11. Seated Pike Lift Using large dumbbells or blocks,

lift buttocks off table and hold for 20 seconds. Target muscle,
lower trapezius.

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Figure 12. Standing snow angels - Stand with back against wall, keeping scapula, back of hands, and forearms touching wall.
Move hands to overhead pressing motion then return with arms to side. Light cuff weights are used to provide additional resistance.

capsule. Implementation of the scapular program can

begin early in the rehabilitation protocol and progress to more aggressive strengthening approaches.
Scapular strengthening should be a part of all rehabilitation programs relating to the shoulder complex.
Advancement in the knowledge of shoulder complex
biomechanics and related EMG patterns has allowed
for the development of strengthening exercises that
maximally address these anchor muscles. As techniques evolve to objectively measure scapular position and dynamic function, the interaction between
the scapula and glenohumeral joint can be further
clarified.
REFERENCES
Figure 13. Scapular shirt Scapular shirt used to help maintain proper posture and scapular positioning.

of the scapula. An effective scapular strengthening

program is especially important for the overhead athlete or swimmer where normal scapular firing and
control may have an effect on performance and may
also relate to injury prevention. Weakness of these
anchoring muscles may lead to altered biomechanics of the glenohumeral joint with resultant excessive stress imparted to the rotator cuff and anterior

1. Voight ML, Thomson BC. The role of the scapula

in the rehabilitation of shoulder injuries. J Athl
Training. 2000;35(3):364-372.
2. Paine RM, Voight ML. The role of the scapula.
J Orthop Sports Phys Ther. 1993;18:386-391.
3. Peat M. Functional anatomy of the shoulder
complex. Phys Ther. 1986;66:1855-1865.
4. Bigliani LU, Codd TP, Connor PM, Levine WN.
Shoulder motion and laxity in the professional
baseball player. Am J Sports Med. 1997;25:609-613.
5. Kamkar A, Irrgang JJ, Whitney SL. Nonoperative
management of secondary shoulder impingement

The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 627

6.
7.

8.
9.

10.

syndrome. J Orthop Sports Phys Ther. 1993;17:212224.

Pink M, Jobe FW. Shoulder injuries in athletes. Clin
Manage. 1991;11:39-47.
Jobe FW, Pink M. Classication and treatment of
shoulder dysfunction in the overhead athlete.
J Orthop Sports Phys Ther. 1993;18:427-432.
Kibler WB. The role of the scapula in athletic
shoulder function. Am J Sports Med. 1998;26:325-337.
DiVeta J, Walker ML, Skibinski B. Relationship
between performance of selected scapular muscles
and scapular abduction in standing subjects. Phys
Ther. 1990;70:470-476
Ludewig PM, Cook TM, Nawoczenski DA. Threedimensional scapular orientation and muscle
activity at selected positions of humeral elevation.
J Orthop Sports Phys Ther. 1996;24:57-65.

11. McClure PW, Michener LA, Sennett BJ, Karduna AR.

Direct 3-dimesional measurement of scapular
kinematics during dynamic movements in vivo.
J Shoulder Elbow Surg. 2001;10:269-277. http://dx.doi.
org/10.1067/mse.2001.112954
12. Kibler WB. Role of the scapula in the overhead
throwing motion. Contemp Orthop. 1991;22:525-532.
13. DiGiovine NM, Jobe FW, Pink M, Perry J. An
electromyographic analysis of the upper extremity
in pitching. J Shoulder Elbow Surg. 1992;1:15-25.
14. Reinold MM, Escamilla R, Wilk KE. Current concepts
in the scientic and clinical rationale behind
exercises for glenohumeral and scapulothoracic
musculature. J Orthop Sports Phys Ther. 2009;39:105117.
15. Kibler WB, Ludewig PM, McClure PW, et al. Clinical
implications of scapular dyskinesis in shoulder
injury: the 2013 consensus statement from the
scapular summit. Br J Sports Med. Published online
rst: 11 April 2013. doi:10.1136/bjsports-2013-092425.
16. Inman VT, Saunders M, Abbott LC. Observations on
the function of the shoulder joint. J Bone Joint Surg
Am. 1944;26:1-30.
17. Lukasiewicz AC, McClure P, Michener L, Pratt N,
Sennett B. Comparison of 3-dimensional scapular
position and orientation between subjects with and
without shoulder impingement. J Orthop Sports Phys
Ther. 1999;29:574-586.
18. Ludewig PM, Behrens SA, Meyer SM, Spoden SM,
Wilson LA. Three-dimensional clavicular motion
during arm elevation: reliability and descriptive
data. J Orthop Sports Phys Ther. 2004;34:140-149.
19. Treece RM, Lunden JB, Lloyd AS, Kaiser AP,
Cieminski CJ, Ludewig PM. Three-dimensional
acromioclavicular joint motions during elevation of
the arm. J Orthop Sports Phys Ther. 2008;38:181-190.

20. Borstad JD, Ludewig PM. Comparison of scapular

kinematics between elevation and lowering of the
arm in the scapular plane. Clin Biomech. 2002;17:
650-659.
21. Ludewig PM, Reynolds JF. The association of
scapular kinematics and glenohumeral joint
pathologies. J Orthop Sports Phys Ther. 2009;39:
90-104.
22. Moseley JB Jr, Jobe FW, Pink M, Perry J, Tibone JE.
EMG analysis of the scapular muscles during a
scapular rehabilitation program. Am J Sports Med.
1992;20:128-134.
23. Kuhn JE, Plancher KD, Hawkins RJ. Scapular
winging. J Am Acad Orthop Surg. 1995;3:319-325.
24. Pink M, Perry J. Biomechanics. In Jobe FW, ed.
Operative Techniques in Upper Extremity Sports
Injuries. St. Louis, MO:Mosby;1996:109-123.
25. Glousman R, Jobe FW, Tibone JE, Moynes D,
Antonelli D, Perry J. Dynamic electromyographic
analysis of the throwing shoulder with glenohumeral
instability. J Bone Joint Surg Am. 1988;70:220-226.
26. Warner JJ, Micheli LJ, Arslenian LE, Kennedy J,
Kennedy R. Scapulothoracic motion in normal
shoulders and shoulders with glenohumeral
instability and impingement syndrome: a study
using Moire topographic analysis. Clin Orthop.
1992;285:191-199.
27. Thomson BC, Mitcheli LJ. The effects of repetitive
exercise of the shoulder on the lateral scapular
stability. Presented at: American Physical Therapy
Association Combined Sections Meeting; February
2000; New Orleans, LA.
28. Carpenter JE, Blasier RB, Pellizon GG. The effects of
muscle fatigue on shoulder joint position sense. Am
J Sports Med. 1998;26:262-265.
29. Voight ML, Hardin JA, Blackburn TA, Tippett SR,
Canner GC. The effects of muscle fatigue on and the
relationship of arm dominance to shoulder
proprioception. J Orthop Sports Phys Ther.
1996;23:348-352.
30. Koslow PA, Prosser LA, Strony GA, Suchecki SL,
Mattingly GE. Specicity of the lateral scapular slide
test in asymptomatic competitive athletes. J Orthop
Sports Phys Ther. 2003;33(6):331336.
31. Philip McClure, Angela R. Tate, Stephen Kareha,
Dominic Irwin, and Erica Zlupko (2009) A Clinical
Method for Identifying Scapular Dyskinesis, Part 1:
Reliability. J Athl Train 2009;(44)2:160-164.
32. Myrer JW Schulthies SS, Fellingham GW. Relative
and absolute reliability of the KT-2000 arthrometer
for uninjured knees: testing at 67,89, 134, and 178 N
and manual maximum forces. Am J Sports Med.
1996;24:104-108.

The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 628

33. Borich MR, Bright JM, Lorello DJ, et al. Scapular

angular positioning at end range internal rotation
in cases of glenohumeral internal rotation decit
J Orthop Sports Phys Ther. 2006;36:926-34
34. Laudner, Kevin G, Moline, Mike T, Meister, Keith.
The relationship between forward scapular posture
and posterior shoulder tightness among baseball
players. Am J Sports Med. 2010;(38): 2106-2112.
35. Laudner KG, Stanek JM, Meister K. Differences in
scapular upward rotation between baseball pitchers
and position players. Am J Sports Med 2007;(35)12:
2091-2095.
36. Paine RM, Johnson RJ. (2009) Conditioning, training,
and rehabilitation for the golfers shoulder. In The
Athletes Shoulder 2nd Edition. 465-491. Churchill
Livingstone Elsevier Philadelphia PA.
37. Kibler WB, Sciascia AD, Uhl TL, et al.
Electromyographic analysis of specic exercises for
scapular control in early phases of shoulder
rehabilitation. Am J Sports Med. 2008:(36)9:17891798.

38. Ekstrom RA, Donatelli RA, Soderberg GL. Surface

electromyographic analysis of exercises for the
trapezius and serratus anterior muscles. J Orthop
Sports Phys Ther 2003;33:24758.
39. Reinold MM, Escamilla RF, Wilk KE. Current
concepts in the scientic and clinical rationale
behind exercises for glenohumeral and
scapulothoracic musculature. J Orthop Sports Phys
Ther. 2009;39:10517.
40. Decker MJ, Hintermeister RA, Faber KJ, et al.
Serratus anterior muscle activity during selected
rehabilitation exercises. Am J Sports Med
1999;27:78491.
41. Hintermeister RA, Lange GW, Schultheis JM, et al.
Electromyographic activity and applied load during
shoulder rehabilitation exercises using elastic
resistance Am J Sports Med 1998;26:21020.
42. Moseley JB Jr, Jobe FW, Pink M, et al. EMG analysis
of the scapular muscles during a shoulder
rehabilitation program. Am J Sports Med 1992;20:
12834.

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